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New NICE bisphosphonate guidance taken to task

News, 30 January 2018

Leading osteoporosis experts have warned GPs and health professionals to exercise caution over recently issued guidance about the use of bisphosphonates.

The new guidance, published by NICE during the summer, incorporates both fracture risk assessment tools and the availability of low-cost generic forms of bisphosphonates and concludes these drugs are cost-effective at very low fracture risk thresholds.

The appraisal recommends treatment with oral bisphosphonates for people with a probability of major osteoporotic fracture (eg, hip, spine, wrist, or humerus) that exceeds 1% over 10 years and treatment with intravenous bisphosphonates for those with a probability of more than 10%.

At the time NICE’s Professor Carole Longson MBE said the guidance would “provide clarity for health professionals about when to start treatment with bisphosphonates and provide people who have osteoporosis with access to the most cost-effective treatments to prevent them getting a fracture.”

But, in a letter published in leading health journal the Lancet,clinicians including Nicholas Harvey, Juliet Compston, John Kanis and Eugene McCloskey warned that “the strict application of cost-effectiveness thresholds for inexpensive drugs might lead to counterintuitive and potentially harmful guidance.”

“Unthinking assimilation of the NICE multiple technology appraisal risks a generation of older individuals taking a bisphosphonate regardless of the individual benefit-to-risk ratio and an increased burden of rare long-term side-effects across the population. Given recent debates about the role of pharmaceutical interventions in the prevention of several chronic noncommunicable diseases, this would be an unexpected and unwelcome consequence of national guidance,” the letter concludes.

The National Osteoporosis Society’s Clinical Director Fizz Thompson said the letter highlighted an important issue.

“The National Osteoporosis Society works hard to ensure people affected by osteoporosis have access to a range of safe and effective treatments and that the benefits of those treatments outweigh the risks. It will be important that prescribing clinicians understand the concerns expressed in this letter and use existing expert guidance to help guide decision making so that these drugs are used appropriately.”